LongTerm Care Functional Eligibility

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Long-Term Care Summer Camp August 25, 2009

• Long-Term Care Functional Eligibility

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History

• The Long-Term Care Functional Screen (LTCFS) has
  been under development since 1997.
• Family Care pilot counties have been using the
  LTCFS since 1998
• Used to determine functional eligibility for
  States five Medicaid waiver programs
• COP, CIP, IRIS, Family Care, and Family Care
  Partnership/PACE

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Computer-based

• Computer application incorporates complex logics
  that interpret entered data to determine where
  applicant meets a nursing home level of care
• Tested for reliability and validity and approved
  by the Centers for Medicare and Medicaid Services
• Level of care determined by the LTCFS also
  triggers the monthly payment amount to the MCO
  for that person.

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Functional Needs Assessment

• Describes assistance consumer needs with
• Activities of Daily Living
• Instrumental Activities of Daily Living
• Health-related Tasks (including skilled nursing)
• Diagnoses
• Behavioral Symptoms Cognition
• Risk Factors
• Mental Health Substance Abuse

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Activities of Daily Living

• Activities of daily living or ADLs means
  bathing, dressing, eating, mobility, transferring
  from one surface to another such as bed to chair
  and using the toilet. Wis. Admin. Code. DHS
  10.13(7)(1m).

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Instrumental Activities of Daily Living

• Instrumental activities of daily living or
  IADLs means management of medications and
  treatments, meal preparations and nutrition,
  money management, using the telephone, arranging
  and using transportation and the ability to
  function at a job site. Wis. Admin. Code DHS
  10.13(7)(32).

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Risk of Institutionalization

• LTCFS may find an individual eligible in the
  absence of the requirements found in the Family
  Care statute based on certain medical
  interventions as identified in the Health
  Related Services section or if the worker notes
  that the individual is at imminent risk of
  institutionalization.

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Supporters Detractors

• Pros
• Instantaneous eligibility determinations upon
  entering data
• Objective (?)
• Cons
• No way to know why a particular individual is
  ineligible
• Inconsistent application/gathering of data
• Opportunities to manipulate results

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Limitations

• LTCFS is only a brief functional needs assessment
  to determine program eligibility
• Provides baseline for more in-depth assessment to
  develop service plan, i.e., MCOs Comprehensive
  Assessment
• Does not reflect consumers strengths, values,
  and preferences

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LTCFS Screeners

• B.A. or combination of post-secondary education
  and experience
• Those screening individuals with a DD must be
  qualified as QMRPs
• Training requirements
• Completion of web-based certification course
• Pass Screener Certification exam at conclusion of
  course
• Experience working with LTC consumers

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Screening Requirements

• ADRCs should be the primary spot for the
  administration of the LTCFC for the home and
  community-based waiver (HCBW) programs
• Initial screen and annual screens thereafter to
  ensure continued functional eligibility
• MCOs may administer annual rescreens
• Conflict of Interest?

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Screening Requirements

• Whenever the condition of a person in a LTC
  program changes substantially, the LTCFS should
  be updated
• Consumers can always request a new screen

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Non-Financial Eligibility

• Age
• Minimum of 18 years of age
• Consumers age 17 years and 9 months or older may
  be screened by the LTCS to allow for advance
  planning
• Residency
• Must be a resident of Family Care county
• Acceptance of MA, if eligible
• Be a member of a Family Care Target Group

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Family Care Target Groups

• Three Target Groups
• Frail Elder
• Person with Physical Disability
• Personal with Development Disability

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Target Group Frail Elders

• An individual age 65 or older who has a physical
  disability, or an irreversible dementia, that
  restricts the individuals ability to perform
  normal daily tasks or that threatens the capacity
  of the individual to live independently

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Target Group Physical Disability

• A physical condition, including an anatomical
  loss or musculoskeletal, neurological,
  respiratory or cardiovascular impairment, which
  results from injury, disease, or congenital
  disorder and which significantly interferes with
  or significantly limits at least one major life
  activity of a person (Wis. Stat. 15.197(4))

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Target Group Developmental Disability

• Federal State Definitions
• Federal
• Meets level described in the American Association
  on Mental Retardations Manual on Classification
  in Mental Retardation, or
• A related condition as defined by 42 CFR
  435.1009, a severe, chronic disability that meets
  the several conditions, including
• Manifests before age 22
• Results in substantial functional limitations in
  three or more major life activities

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Target Group Developmental Disability

• State
• Broader than Federal definition
• A disability attributable to brain injury,
  cerebral palsy, epilepsy, autism, Prader-Will
  syndrome, mental retardation, or another
  neurological conditional closely related to
  mental retardation or requring treatment to that
  required for mental retardation, which has
  continued or can be expected to continue
  indefinitely and constitutes a substantial
  handicap to the afflicted individual (Wis. Stat.
  51.01(5)(a))

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Family Care Levels of Care

• For Family Care, Family Care Partnership, and
  IRIS, there are two levels of eligibility
• Nursing Home Level of Care
• Includes all NH eligible people, including DD
  level of care
• Non-Nursing Home Level of Care

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Family Care Levels of Care

• Non-Nursing Home Level of Care
• Individuals who are found ineligible for some LTC
  programs may still be found functional eligible
  for Family Care at the Non-Nursing Home Level of
  Care
• No Social Security disability determination is
  necessary for the Non-Nursing Home Level of Care
• Family Care members receive case management
• Services are limited to Medicaid card services.
• See 2009 Family Care Programs Contract, pgs.
  184-85.

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Basis in Law

• Wisconsin Family Care statutes and regulations
  define the conditions for functional eligibility
• If consumer meets legal definition but LTCFS
  indicates ineligibility, the LTCFS results are
  invalid
• Long-term condition AND meets requirements of
  comprehensive or intermediate functional capacity
  levels

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Basis in Law

• Wis. Admin. Code. DHS 10.33
• Long-term condition and
• Meets requirements for either comprehensive or
  intermediate functional capacity levels
• Comprehensive functional capacity NH LOC
• Intermediate functional capacity Non-NH LOC
• At this time, Family Care statutes and
  regulations do not apply to Partnership or IRIS

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Nursing Home Level of Care

• Nursing Home Level of Care (formerly
  Comprehensive NH LOC)
• Long-term or irreversible condition, and
• Inability to safely perform, as follows
• 3 or more activities of daily living (ADLs)
• 2 or more ADLs and 1 or more instrumental
  activities of daily living (IADLs)
• 1 or more ADLs, 3 or more IADLs, and individual
  has a cognitive impairment
• 4 or more IADLs and individual has a cognitive
  impairment or

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Nursing Home Level of Care

• Individual has a complicating condition that
  limits his or her ability to independently meet
  his or her needs and
• The person requires frequent medical or social
  intervention to safely maintain an acceptable
  health or developmental status, or requires
  changes in service due to intermittent or
  unpredictable changes in his or her condition, or
  requires a range of medical or social
  interventions due to a multiplicity of
  conditions and
• The person has a developmental disability that
  requires specialized services, or has impaired
  cognition exhibited by memory deficits or
  disorientation to person, place, or time, or has
  impaired decision-making ability exhibited by
  wandering, physical abuse of self or others,
  self-neglect, or resistance to needed care.

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Non-Nursing Home Level of Care

• Non-Nursing Home Level of Care (formerly
  Intermediate and Comprehensive non-NH LOC)
• Long-term or irreversible condition, and
• At risk of losing independence of functional
  capacity as evidenced by either of the following
• Inability to safely perform one or more ADL or
• One or more of the following critical IADLs
• Management of medications and treatments
• Meal preparation and nutrition and/or
• Money management

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Self-Advocacy

• Be honest and thorough in answering screeners
  questions
• Focus on worst day
• Break down each task
• Consumer can choose time and place
• Consumer can choose to have others present for
  the screen
• Consider requesting a new screen

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LTCFS Appeals

• Consult with DHS LTCFS professionals
• Request a review by MetaStar, States external
  quality review organization
• Request a State fair hearing
• May request appeal of either ADRC or MCO screen
• Right to free copies of documents relevant to
  screen as well as any collateral information
  collected as part of screen
• Contact Family Care Ombudsman Program

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Resources

• DHS website provides information about the LTCFS,
  including the instructions
• Screen Instructions
• http//dhs.wisconsin.gov/ltcare/FunctionalScreen/L
  TCFSinstrux-clean.pdf
• DHS LTCFS Website
• http//dhs.wisconsin.gov/LTCare/FunctionalScreen/